Cardiovascular Flashcards
What is a false aneurysm or pseudoaneurysm?
when does it occur?
when the two inner layers of the aorta (intima and media) rupture and there dilation of the vessel, with the blood being contained by the outer layer (adventita).
Occurs from trauma or after surgery to aorta or infection in vessels
What true aneurysm?
where all 3 layers of aorta is intact but dilated
what is aortic dissection?
where blood enters between the intima and media layer
Who are more affected by thoracic aortic aneurysm?
What are some of the other risk factors of thoracic aortic aneurysm?
Men and also at younger age than women.
risk factors:
- increased age
- smoking
- hypertension
- family history
- Marfan Syndrome or other connective tissue disorder
- existing cardio disease.
Does dilation of thoracic aorta cause symptoms?
What are the symptoms of thoracic aneurysm due to it taking up space in the mediastinum?
No symptoms - only found incidentally.
Symptoms include:
- Chest or back pain
- Trachea or left bronchus compression may cause cough, SOB, and stridor.
- phrenic nerve compression cause hiccups
- Oesophageal compression cause dysphagia (difficulty swallowing)
- recurrent laryngeal nerve compression cause hoarse voice
What investigations can be done for the diagnosis of thoracic aortic aneurysm?
- Echocardiogram
- CT or MRI angiogram
Management of thoracic aortic aneurysm?
what would be does if the aneurysm was large
- treat modifiable risk factors (smoking, diet, management of hypertension, diabetes and hyperlipidaemia)
Options vary depending on size, larger is likely to rupture, management options include:
- Surveillance with regular imaging to monitor the size
- Thoracic endovascular aortic repair (TEVAR), with a catheter inserted via the femoral artery inserting a stent graft into the affected section of the aorta
- Open surgery (midline sternotomy) to remove the section of the aorta with the defect in the wall and replace it with a synthetic graft
where does a ruptured thoracic aortic aneurysm bleed into? and what can this cause?
- Oesophagus, causing haematemesis (vomiting blood).
- Airways or lungs, causing haemoptysis (coughing up blood)
- Pericardial cavity, causing cardiac tamponade (compression of the heart)
What does ruptured thoracic aortic aneurysm present as?
- severe chest pain or back pain
- haemodynamic instability (hypotension and tachycardia).
- Collapse
- Death (often patients do not reach hospital).
- Emergency open surgery is required, replace affected area from synthetic graft.
What scoring system is used to calculate the percentage risk of a patient will have stroke or MI, in the next 10 years? What statin is given to patients with above 10% risk? - what are patients are given this statin?
QRISK 3 score - if you have more than 10% risk of having stroke or MI in the next 10 years, patients SHOULD start statin - Nice guidelines are for atorvastatin 20mg at night.
Patients with CKD or type 1 diabetes for the 10 years should be offered atorvastatin 20mg.
What are the 4 As for secondary prevention after developing cardiovascular disease?
- Aspirin (plus a second anti-platelet such as clopidogrel for 12 months).
- Atorvastatin 80mg
- Atenolol (commonly bisoprolol)
- ACE inhibitor (commonly ramipril)
What are the notable side effects of statin?
- Myopathy (check creatine kinase in patients with muscle pain or weakness)
- Type 2 diabetes
- Haemorrhage strokes (very rarely)
What is an angina?
narrowing of the coronary arteries which then reduces blood flow to the myocardium
What is the classic symptom of angina?
Constricting chest pain with or without radiation to jaw or arms.
What is stable and unstable angina?
- Stable is when symptoms are relieved by rest or glyceryl trinitrate (GTN).
- Unstable is when symptoms comes on at rest and is considered as acute coronary syndrome (ACS)
What is the gold started diagnostic investigation for angina?
CT coronary angiography.
Also do:
- Physical Examination (heart sounds, signs of heart failure, BMI)
- ECG
- FBC (check for anaemia)
- U&Es (prior to ACEi and other meds)
- LFTs (prior to statins)
- Lipid profile
- Thyroid function tests (check for hypo / hyper thyroid)
- HbA1C and fasting glucose (for diabetes)
What are the 4 principles to management for angina? RAMP
R - refer to cardio urgent
A - advise them about diagnosis, management and call ambulance
M - medical treatment
P - procedural or surgical intervention
Medical management of angina: immediate symptomatic relief
- GTN
repeat after 5 minutes and if still pain repeat after 5 and call ambulance.
Medical management of angina: Long term symptomatic relief
1) used on its own or in combo if symptoms are not controlled: Beta blocker (e.g. bisoprolol 5mg once daily) or Calcium channel blocker (e.g. amlodipine 5mg once daily).
Other options (not 1st line):
- Long acting nitrates (e.g. isosorbide mononitrate)
- Ivabradine
- Nicorandil
- Ranolazine
Medical management of angina: Secondary prevention
- Aspirin (i.e. 75mg once daily)
- Atorvastatin 80mg once daily
- ACE inhibitor
- Already on a beta-blocker for symptomatic relief.
What are the surgical intervention for angina?
1) Percutaneous Coronary intervention (PCI) with coronary angioplasty (dilating the blood vessels with a balloon or inserting a stent).
2) Coronary Artery bypass graft (CABG) - for patients with severe stenosis. Takes graft vein from patients leg (great saphenous vein).
Patients with coronary artery disease may have midline sternotomy scar (CABG) or scars around brachial and femoral arteries (PCI)
What is Acute coronary syndrome (ACS)?
blockage of coronary artery as a result of thrombus from an atherosclerotic plaque. Thrombus formed in fast flowing artery are mostly made of platelets hence the anti-platelet medications
The left coronary artery becomes the Circumflex and Left Anterior Descending (LAD), what do these supply?
Circumflex artery - Left atrium and posterior aspect of the left ventricle.
Left anterior descending (LAD): anterior aspect of left ventricle and anterior aspect of the septum
What does the right coronary artery (RCA) supply?
- Right atrium
- Right ventricle
- Inferior aspect of left ventricle
- Posterior septal area
